Đăng ký tham gia hội nghị Gây mê hồi sức ASEAN lần thứ 14

14th ASEAN congress of Anaesthesiologists

HANOI 23-25.11.2005

A. REGISTRATION FORM

Please complete the form below.
Registrations will only be accepted if all information marked with a * is completed.

Surname :

First Name :

Title : *

	Prof		Dr		Mr		Mrs		Ms

Sex:

Institution :

Department:

Address: :

City: :

Zip Code :

Country :

Telephone :

Fax

E-mail :

Attendance as a Speaker? Yes No

Submission of Paper? Yes No

- Accompanying persons :

No	Surname	First Name	Age	Sex	Relationship
1
2
3

Fees :   Before 30.9.2005 :       200 USD
           After    30.9.2005 :       250 USD
              Accompanying person and students will be offered HALF mentioned fee

Total A:

B. NEED FOR HOTEL (Please refer to the Hotel information for detail)
Category: Single: Double:
-	Arrival at the airport	Hotel check in	Departure at the airport	Hotel check out
Date	-	-	-	-
Time	:	:	:	:
Flight Number
Number of nights:
TOTAL B:

C. SOCIAL PROGRAMME
(Please refer to the Tourism informations for detail)


Tour	Date	Group size
ITC-03: HANOI – Half Day Tour	-
ITC-04: HANOI – One Day Tour	-
ITC-05: HANOI- HALONG -HANOI - (2 days/1 night, with guide)	-
ITC-06: HANOI- HALONG -HANOI - (2 days/1 night, without guide)	-
ITC-07: HANOI- HALONG -HANOI - (1 day, with guide)	-
ITC-08: HANOI- HALONG -HANOI - (1 day, without guide)	-
ITC-09: HANOI- HALONG -HANOI - (2 days/1 night, overnight on board/ with guide)	-
ITC-10: HANOI- HALONG -HANOI - (2 days/1 night, overnight on board/ without guide)	-
ITC-11: Hanoi- halong- hue- danang- hoian- saigon (7days/6nights)	-
ITC-12: Central stop over: Hanoi- halong- hue- danang- hoian- hanoi	-
ITC-13: Sapa - a town in foggy Ha Noi – Sa pa – Bac Ha (2 days– 3 nights–by train, departure every Friday night)	-
ITC-14: Hanoi – Sapa – Bac Ha (4 days – 5 nights, by train)	-

All advanced payment is only possible via Bank Transfer quoting the exact amount due.

BANK ACCOUNT: For payment in USD: 0011371111224

For payment in Euro: 0011141111532

At: VIETCOMBANK, 198 Tran Quang Khai Str, Hanoi, Vietnam.

Swift code: BFTVVNVX

Benefit’s name: Vietnam Society of Anaesthesiologists.

Please scan or fax copy of transfer order to ensure the us checking the bank account.

For futher information, please contact: 14 ASEAN Secretariat-cashier: Dr. Le Tuyen
Hong Duong, asean14@vnanesth.org

PRINT VERSION: To download a print version of the registration form, please click HERE. Then please post your completed form to the following address:

Dr. Cong Quyet Thang

No 1, Tran Khanh Du Str. Ha Nội - Viet Nam.
Anesthesiologists Dept. Huu Nghi Hospital.

E-mail: cqthang2005@fpt.vn
Tel: 84 4 9 723 760
Fax: 84 4 9 723 759

Or fax your completed registration form to the following fax number: 84 4 9 723 759

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